Healthcare Provider Details

I. General information

NPI: 1992212161
Provider Name (Legal Business Name): EXOFFENDER TRANSITION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 S WABASH AVE REAR
CHICAGO IL
60616-2825
US

IV. Provider business mailing address

2630 S WABASH AVE REAR
CHICAGO IL
60616-2825
US

V. Phone/Fax

Practice location:
  • Phone: 312-808-3210
  • Fax: 312-949-1610
Mailing address:
  • Phone: 312-808-3210
  • Fax: 312-949-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE LANG APPLEWHITE
Title or Position: VICE PRESIDENT & CLINICAL DIRECTOR
Credential: MSP, CADC, LCPC
Phone: 312-808-3210